Changing roles in community health care: Delegation of insulin injections to health care support workers

Delegation of insulin administration: a survey of community nursing teams in England

In community nursing, the administration of insulin for people with type 2 diabetes can be delegated by registered nurses to healthcare support workers. Although a voluntary framework in England provides national guidance, little is known about its uptake. The project aim was to determine the roll-out, characteristics and support needs in relation to the delegation of insulin administration in community settings. An online survey was disseminated to community nursing services in England via social media and nursing networks. Of the 115 responding organisations, 81% (n=93) had an insulin delegation programme, with most initiated since 2018. From these services, 41% (n=3704) of insulin injections were delegated daily, with benefits for patients, staff and services reported, along with some challenges. Delegation of insulin administration is an established and valued initiative. Awareness of the national voluntary framework is increasing. National guidance is considered important to support governance arrangements and safety.

Delegation of insulin administration to non-registered healthcare workers in community nursing teams: A qualitative study

AIMS

To explore stakeholder perspectives on the benefits and/or disadvantages of the delegation of insulin injections to healthcare support workers in community nursing services.

DESIGN

Qualitative case study.

METHODS

Interviews with stakeholders purposively sampled from three case sites in England. Data collection took place between October 2020 and July 2021. A reflexive thematic approach to analysis was adopted.

RESULTS

A total of 34 interviews were completed: patients and relatives (n = 7), healthcare support workers (n = 8), registered nurses (n = 10) and senior managers/clinicians (n = 9). Analysis resulted in three themes: (i) Acceptance and confidence, (ii) benefits and (iii) concerns and coping strategies. Delegation was accepted by stakeholders on condition that appropriate training, supervision and governance was in place. Continuing contact between patients and registered nurses, and regular contact between registered nurses and healthcare support workers was deemed essential for clinical safety. Services were reliant on the contribution of healthcare support workers providing insulin injections, particularly during the COVID-19 pandemic. Benefits for service and registered nurses included: flexible team working, increased service capacity and care continuity. Job satisfaction and career development was reported for healthcare support workers. Patients benefit from timely administration, and enhanced relationships with the nursing team. Concerns raised by all stakeholders included potential missed care, remuneration and task shifting.

CONCLUSION

Delegation of insulin injections is acceptable to stakeholders and has many benefits when managed effectively.

IMPACT

Demand for community nursing is increasing. Findings of this study suggest that delegation of insulin administration contributes to improving service capacity. Findings highlight the essential role played by key factors such as appropriate training, competency assessment and teamwork, in developing confidence in delegation among stakeholders. Understanding and supporting these factors can help ensure that practice develops in an acceptable, safe and beneficial way, and informs future development of delegation practice in community settings.

PATIENT OR PUBLIC CONTRIBUTION

A service user group was consulted during the design phase prior to grant application and provided comments on draft findings. Two people with diabetes were members of the project advisory group and contributed to the study design, development of interview questions, monitoring study progress and provided feedback on study findings.

Exploring the Knowledge Structure of Patient Safety in Nursing Using a Keyword Network Analysis

Patient safety is a critical and long-standing issue in nursing research. The purposes of this study were to explore the knowledge structure of patient safety and to provide a direction for future research by offering new perspectives and a theoretical clarification of patient safety in nursing. Keyword network analysis was performed by extracting keywords from abstracts of 6072 published articles. To reflect nursing perspectives, focus group interviews were conducted and Kim's typology consisting of four domains was used as the framework of analysis. Visualized knowledge structure showed avoiding medication error and preventing pressure ulcers or falls remain important topics within this research field. The distribution of core keywords as per four domains was in the following order: practice, client, environment, and client-nurse domain. Within the client domain, patients' harm-related core keywords were limited to physical harm. The detailed knowledge structure consisted of five themes: patient, preventable patient harm, practice, error, and environment. It comprised risk assessment for patients' characteristics and environmental elements surrounding patient and nursing practice, and risk management using information as knowledge-based nursing practice. Regarding further research, we suggest a multidimensional approach to patient harm, and the utilization of the client-nurse relationship and information systems as strategies for patient safety.

Delegation of medication administration from registered nurses to non-registered support workers in community care settings: A systematic review with critical interpretive synthesis

INTRODUCTION

Healthcare workforces are currently facing multiple challenges, including aging populations; increasing prevalence of long-term conditions; and shortfall of registered nurses. Employing non-registered support workers is common across many countries to expand service capacity of nursing teams. One task delegated to non-registered support workers is medication administration, which is considered a complex task, with associated risks. This is an important topic given the predicted global increase in patients requiring assistance with medication in community settings. This review explores the evidence on delegation of medication administration from registered nurse to non-registered support workers within community settings, to better understand factors that influence the process of delegation and its impact on service delivery and patient care.

METHODS

The review followed key principles of Critical Interpretative Synthesis and was structured around Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Literature searches were conducted in MEDLINE, CINAHL, Embase, and ProQuest-British Nursing Index databases. Twenty studies were included.

RESULTS

Findings are reported under four themes: 1, Regulatory and contextual factors; 2, Individual and team level factors; 3, Outcomes of delegation; and 4, Process of implementation and evaluation. Delegation was found to be a complex phenomenon, influenced by a myriad of interconnecting factors at the macro, meso, micro level. At the macro level, the consistency and clarity of government and state level regulations was found to facilitate or impede delegation of medication administration. Lack of clarity at the macro level, impacted at meso and micro levels, resulting in confusion around what medication administration could be delegated and who held responsibility. At the micro level, central to the interpretation of success was the relationship between the delegator and delegatee. This relationship was influenced by personal views, educational and systems factors. Many benefits were reported as an outcome of delegation, including service efficiency and improved patient care. The implementation of delegating medication administration was influenced by regulatory factors, communication, stakeholder engagement, and service champions.

CONCLUSION

Delegation of medication administration is a complex process influenced by many interrelating factors. Due to the increased risk associated with medication administration, clear and consistent regulatory and governance frameworks and procedures are crucial. Delegation of medication administration is more acceptable within a framework that adequately supports the process, backed by appropriate policy, skills, training, and supervisory arrangements. There is a need for further research around implementation, clinical outcomes and medication errors associated with delegation of medication administration.